<?php
$this->load->view('enrollment/enrollment_modal');
$genderAttrib = array('' => 'Select Gender...', 'male' => 'Male', 'female' => 'Female' );
$child_birth_position = array(''=>'','first'=>'First','Second'=>'Second','third'=>'Third','fourth'=>'Fourth','fifth'=>'Fifth','sixth'=>'Sixth','youngest'=>'youngest','only'=>'Only');
?>
<div class="row">
<div class="large-12 columns enrollment-menu  content-views">
<? echo $system_message;?>
<div class="alert-box">REGISTRATION FORM Part 2: Developmental History of Child And Childhood Experiences</div>
<?$this->load->view('enrollment/notice')?>
<?echo form_open('developmental','class="custom" id="check-form-submit" data-abide  autocomplete="off"');?>
	<div class="alert-box secondary">Developmental History Of Child</div>
	<div class="row">
		<div class="large-8 small-12 columns">
			<label>Length of Pregnancy<span>&#10033;</span></label>
			<?=form_error('length_of_preg');?>
			<input type="text" name="length_of_preg" value="<?=set_value('length_of_preg');?>" required>
			<small class="error">This field is required.</small>
		</div>
		<div class="large-4 small-12 columns">
			<label>Form of Delivery<span>&#10033;</span></label>
			<?=form_error('form_of_del');?>
			<input type="text" name="form_of_del" value="<?=set_value('form_of_del');?>" required>
			<small class="error">This field is required.</small>
		</div>
	</div>
	<div class="row">
		<div class="large-12 columns">
		<label>Complications before? during? after? delivery?<span>&#10033;</span></label>
		<?=form_error('complications');?>
		<input type="text" name="complications" value="<?=set_value('complications');?>" required>
		<small class="error">This field is required.</small>
		</div>
	</div>
	<div class="row">
		<div class="large-4 columns">
			<label>What time does the child go to bed?<span>&#10033;</span></label>
			<?=form_error('go_to_bed');?>
			<input type="text" name="go_to_bed" value="<?=set_value('go_to_bed');?>" required>
			<small class="error">This field is required.</small>
		</div>
		<div class="large-4 columns">
			<label>Any sleeping disturbance? if yes what?</label>
			<?=form_error('sleeping_dist');?>
			<input type="text" name="sleeping_dist" value="<?=set_value('sleeping_dist');?>" >
		</div>
		<div class="large-4 columns">
			<label>Get up from bed?<span>&#10033;</span></label>
			<?=form_error('get_up_bed');?>
			<input type="text" name="get_up_bed" value="<?=set_value('get_up_bed');?>" required>
			<small class="error">This field is required.</small>
		</div>
	</div>
	
	<div class="row">
			<div class="large-6 columns">
				<label>Does the child have own room?</label>
				<?=form_error('own_room');?>
				<?=form_dropdown('own_room',array(''=>'-- select --','yes'=>'Yes','no'=>'No'),set_value('own_room'),'required');?>
				<small class="error">This field is required.</small>
			</div>
			<div class="large-6 columns">
				<label>If not, shares with whom?</label>
				<?=form_error('room_shares');?>
				<input type="text" name="room_shares" value="<?=set_value('room_shares');?>">
			</div>
	</div>
	<div class="row">
		<div class="large-4 columns">
			<label>Does the child bed wet?<span>&#10033;</span></label>
			<?=form_error('wet_bed');?>
			<?=form_dropdown('wet_bed',array(''=>'-- select --','yes'=>'Yes','no'=>'No'),set_value('wet_bed'),'required');?>
			<small class="error">This field is required.</small>
		</div>
		<div class="clearfix"></div>
	</div>
	<div class="alert-box secondary">Are there any observable difficulties or defects in your child's growth?<span>&#10033;</span></div>
	<div class="row">
		<div class="large-4 columns">
			<label>Specify:<span>&#10033;</span></label>
			<?=form_error('observable_difficulties');?>
			<input type="text"  name="observable_difficulties" value="<?=set_value('observable_difficulties');?>" >
		</div>
		<div class="large-4 columns">
			<label>Since When?<span>&#10033;</span></label>
			<?=form_error('observable_difficulties_since_when');?>
			<input type="text"  name="observable_difficulties_since_when" value="<?=set_value('since_when');?>">
		</div>
		<div class="large-4 columns">
			<label>Action Taken:<span>&#10033;</span></label>
			<?=form_error('observable_difficulties_action_taken');?>
			<input type="text"  name="observable_difficulties_action_taken" value="<?=set_value('observable_difficulties_action_taken');?>">
		</div>
	</div>
	
	<div class="alert-box secondary">Are there any speech problems?</div>

	<div class="row">
		<div class="large-4 columns">
			<label>Specify:<span>&#10033;</span></label>
			<?=form_error('speech_problems');?>
			<input type="text"  name="speech_problems" value="<?=set_value('speech_problems');?>" >
		</div>
		<div class="large-4 columns">
			<label>Since When?<span>&#10033;</span></label>
			<?=form_error('speech_problems_since_when');?>
			<input type="text"  name="speech_problems_since_when" value="<?=set_value('speech_problems_since_when');?>" >
		</div>
		<div class="large-4 columns">
			<label>Action Taken:<span>&#10033;</span></label>
			<?=form_error('speech_problems_actions_taken');?>
			<input type="text"  name="speech_problems_actions_taken" value="<?=set_value('speech_problems_actions_taken');?>">
		</div>
	</div>
		
	<div class="alert-box secondary">Are there any hearing problems?</div>

	<div class="row">
		<div class="large-3 columns">
			<label>When was the hearing of Child last checked?<span>&#10033;</span></label>
			<?=form_error('hearing_last_checked');?>
			<input type="text"  name="hearing_last_checked" value="<?=set_value('hearing_last_checked');?>">
		</div>
		<div class="large-3 columns">
			<label>Specify:<span>&#10033;</span></label>
			<?=form_error('hearing_problems');?>
			<input type="text"  name="hearing_problems" value="<?=set_value('hearing_problems');?>">
		</div>
		<div class="large-3 columns">
			<label>Since When?<span>&#10033;</span></label>
			<?=form_error('hearing_problems_since_when');?>
			<input type="text"  name="hearing_problems_since_when" value="<?=set_value('hearing_problems_since_when');?>">
		</div>
		<div class="large-3 columns">
			<label>Action Taken:<span>&#10033;</span></label>
			<?=form_error('hearing_problems_actions_taken');?>
			<input type="text"  name="hearing_problems_actions_taken" value="<?=set_value('hearing_problems_actions_taken');?>">
		</div>
	</div>

	<div class="alert-box secondary">Are there any sight problems?</div>
	<div class="row">
		<div class="large-7 columns">
			<label>When was the vision of Child last checked?</label>
			<?=form_error('vision_last_checked');?>
			<input type="text"  name="vision_last_checked" value="<?=set_value('vision_last_checked');?>">
		</div>
		<div class="large-5 columns">
			<label>Specify:<span>&#10033;</span></label>
			<?=form_error('vision_specify');?>
			<input type="text"  name="vision_specify" value="<?=set_value('vision_specify');?>">
		</div>
	</div>
		
	<div>
		<label>Are there any information that we should be aware of that may hinder the child's learning process or general development?<span>&#10033;</span></label>
		<?=form_error('hinder_childs_learning');?>
		<textarea name="hinder_childs_learning" required><?=set_value('hinder_childs_learning');?></textarea>
		<small class="error">This field is required.</small>
	</div>

	
	<div class="alert-box secondary">Childhood Experiences</div>

	<div>
		<label>Has the child encountered any traumatic experiences? if yes specify<span>&#10033;</span></label>
		<?=form_error('traumatic_experiences');?>
		<textarea name="traumatic_experiences"><?=set_value('traumatic_experiences');?></textarea>
	</div>
	<div class="row">
		<div class="large-6 columns">
			<label>Age<span>&#10033;</span></label>
			<?=form_error('age_trauma');?>
			<input type="text" name="age_trauma" value="<?=set_value('age_trauma');?>">
		</div>
		<div class="large-6 columns">
			<label>Reaction<span>&#10033;</span></label>
			<?=form_error('trauma_reaction');?>
			<textarea name="trauma_reaction" ><?=set_value('trauma_reaction');?></textarea>
		</div>
	</div>
	
	<div class="row">
		<div class="large-6 columns">
			<label>How has it affected the child?<span>&#10033;</span></label>
			<?=form_error('how_trauma_affected_child');?>
			<textarea name="how_trauma_affected_child" ><?=set_value('how_trauma_affected_child');?></textarea>
		</div>
		
		<div class="large-6 columns">
			<label>does the child have any special fears?if yes what?<span>&#10033;</span></label>
			<?=form_error('special_fears');?>
			<textarea name="special_fears" ><?=set_value('special_fears');?></textarea>
		</div>
	</div>
	<div class="row">
		<div class="large-6 columns">
			<label>Since when? What has triggered the fear?<span>&#10033;</span></label>
			<?=form_error('when_what_triggered_fear');?>
			<textarea name="when_what_triggered_fear"><?=set_value('when_what_triggered_fear');?></textarea>
		</div>
		<div class="large-6 columns">
			<label>How do you handle it?<span>&#10033;</span></label>
			<?=form_error('how_do_you_handle');?>
			<textarea name="how_do_you_handle"><?=set_value('how_do_you_handle');?></textarea>
		</div>
	</div>
	
	<div class="alert-box secondary">Psycho Social Information</div>
	
	<div class="row">
		<div class="large-4 columns">
			<label>Describe Your Personality<span>&#10033;</span></label>
			<?=form_error('desc_person');?>
			<textarea name="desc_person"><?=set_value('desc_person');?></textarea>
		</div>
		<div class="large-8 columns">
			<label>How would you rate your ability to establish harmonious relationship with others? Why? (5 as the highest rate) <span>&#10033;</span></label>
			<?=form_error('rate_ablity');?>
			<textarea name="rate_ablity"><?=set_value('rate_ablity');?></textarea>
		</div>
	</div>

	<div class="alert-box secondary">Educational Background</div>
	<p class="title">Pre-Elementary</p>
	<div class="row">
		<div class="large-4 columns">
			<label>Inclusive Years</label>
			<?=form_error('pre_elem_years');?>
			<textarea name="pre_elem_years"><?=set_value('pre_elem_years');?></textarea>
		</div>
		<div class="large-4 columns">
			<label>School</label>
			<?=form_error('pre_elem_school');?>
			<textarea name="pre_elem_school"><?=set_value('pre_elem_school');?></textarea>
		</div>
		<div class="large-4 columns">
			<label>Awards Received</label>
			<?=form_error('pre_elem_awards');?>
			<textarea name="pre_elem_awards"><?=set_value('pre_elem_awards');?></textarea>
		</div>
	</div>
	<p class="title">Elementary</p>
	<div class="row">
		<div class="large-4 columns">
			<label>Inclusive Years</label>
			<?=form_error('elem_years');?>
			<textarea name="elem_years"><?=set_value('elem_years');?></textarea>
		</div>
		<div class="large-4 columns">
			<label>School</label>
			<?=form_error('elem_school');?>
			<textarea name="elem_school"><?=set_value('elem_school');?></textarea>
		</div>
		<div class="large-4 columns">
			<label>Awards Received</label>
			<?=form_error('elem_awards');?>
			<textarea name="elem_awards"><?=set_value('elem_awards');?></textarea>
		</div>
	</div>
	<p class="title">Highschool</p>
	<div class="row">
		<div class="large-4 columns">
			<label>Inclusive Years</label>
			<?=form_error('hs_years');?>
			<textarea name="hs_years"><?=set_value('hs_years');?></textarea>
		</div>
		<div class="large-4 columns">
			<label>School</label>
			<?=form_error('hs_school');?>
			<textarea name="hs_school"><?=set_value('hs_school');?></textarea>
		</div>
		<div class="large-4 columns">
			<label>Awards Received</label>
			<?=form_error('hs_awards');?>
			<textarea name="hs_awards"><?=set_value('hs_awards');?></textarea>
		</div>
	</div>
	<p class="title">Kindly rate the following subjects based on your interest (1 is the highest and so on)</p>
	<div class="row">
		<div class="large-12 columns">
		<table class="table table-stripped table-bordered table-compressed">
			<tr>
				<td>
					<input type="text" name="rate_eng" class="underline ratings">
					<label style="display:inline-block;">English</label>
				</td>
				<td>
					<input type="text" name="rate_values" class="underline ratings">
					<label style="display:inline-block;">Values Education</label>
				</td>
			</tr>
			<tr>
				<td>
					<input type="text" name="rate_fil" class="underline ratings">
					<label style="display:inline-block;">Filipino</label>
				</td>
				<td>
					<input type="text" name="rate_live" class="underline ratings">
					<label style="display:inline-block;">Livelihood Education</label>
				</td>
			</tr>
			<tr>
				<td>
					<input type="text" name="rate_math" class="underline ratings">
					<label style="display:inline-block;">Mathematics</label>
				</td>
				<td>
					<input type="text" name="rate_comp" class="underline ratings">
					<label style="display:inline-block;">Computer</label>
				</td>
			</tr>
			<tr>
				<td>
					<input type="text" name="rate_sci" class="underline ratings">
					<label style="display:inline-block;">Science</label>
				</td>
				<td>
					<input type="text" name="rate_robot" class="underline ratings">
					<label style="display:inline-block;">Robotics</label>
				</td>
			</tr>
			<tr>
				<td>
					<input type="text" name="rate_aralpan" class="underline ratings">
					<label style="display:inline-block;">Araling Panlpunan</label>
				</td>
				<td>
					<input type="text" name="rate_mapeh" class="underline ratings">
					<label style="display:inline-block;">MAPEH</label>
				</td>
			</tr>
		</table>
		</div>
	</div>
	<p class="title">Reason/s For enrolling in <?=$school_name;?> (kindly Check the corresponding box for your response)</p>
	<div class="row">
		<div class="large-12 columns">
		<table class="table table-stripped table-bordered table-compressed">
			<tbody>
			<tr>
				<td>
					<input type="checkbox" name="reason[affordable_tuit]" value="1">
					<label style="display:inline-block;">Affordable Tuition Fee</label>
				</td>
				<td>
					<input type="checkbox" name="reason[scholarship_grants]" value="1">
					<label style="display:inline-block;">Scholarship Grants</label>
				</td>
			</tr>
			<tr>
				<td>
					<input type="checkbox" name="reason[near_residence]" value="1">
					<label style="display:inline-block;">Near To Residence</label>
				</td>
				<td>
					<input type="checkbox" name="reason[competent_teachers]" value="1">
					<label style="display:inline-block;">Competent Teachers</label>
				</td>
			</tr>
			<tr>
				<td>
					<input type="checkbox" name="reason[friends_are_here]" value="1">
					<label style="display:inline-block;">Friends Are here</label>
				</td>
				<td>
					<input type="checkbox" name="reason[recommended]" value="1">
					<label style="display:inline-block;">Recomended by parent,relative and friends</label>
				</td>
			</tr>
			<tr>
				<td>
					<input type="checkbox" name="reason[previous_classmates]" value="1">
					<label style="display:inline-block;">Previous classmates and schoolmates are enrolled here.</label>
				</td>
				<td>
					<label style="display:inline-block;">Others Please specify</label>
					<input type="text" name="reason[reason_others]">
				</td>
			</tr>
			<tr>
				<td colspan="2">
					<input type="checkbox" name="reason[parent_graduated]" value="1">
					<label  style="display:inline-block;">Parents Graduated in this institution</label>
				</td>
			</tr>
			<tr>
				<td colspan="2">
					<input type="checkbox" name="reason[developed_facilites]" value="1">
					<label  style="display:inline-block;">Highly Developed Facilities</label>
				</td>
			</tr>
			</tbody>
		</table>
		</div>
	</div>
<div>
	<input type="hidden" name="spm_sdf" value="<?=$token;?>">
	<input type="hidden" name="fillup_developmental" value="true">
	<input type="submit" name="fillup_developmental" value="Continue to Part 3: Health History of Child And Discipline" class="btn btn-primary">
</div>
<?php echo form_close(); ?>
</div>
</div>